National Ethics Teleconference - The Place of Codes of ...



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National Ethics Teleconference

The Place of Codes of Ethics in Ethics Consultation

May 26, 2010

INTRODUCTION

Dr. Berkowitz:

Good day everyone. This is Ken Berkowitz. I am the Chief of the Ethics Consultation Service at the National Center for Ethics in Health Care and a physician at the VA NY Harbor Healthcare System. I am very pleased to welcome you all to today's National Ethics Teleconference. By sponsoring this series of calls, the Ethics Center provides an opportunity for regular education and open discussion of ethical concerns relevant to VHA. Each call features an educational presentation on an interesting or relevant ethics topic followed by an open, moderated discussion of that topic. After the discussion, we reserve the last few minutes of each call for our “From the Field” section. This will be your opportunity to speak up and let us know what is on your mind regarding ethics related topics other than the focus of today's call.

ANNOUNCEMENTS

1. CME credits: are available for listeners of this call. To receive CME credit for this course, you must attend 100% of the call, and complete the registration and evaluation process on the LMS website that is noted on the announcement today, May 26, 2010. If you have any questions about this process or about the LMS website, please contact the Project Manager, John Whatley, PhD, at (205) 731-1812 x312 or by e-mail at John.Whatley@.

2. Ground Rules: Before we proceed I need to briefly review the overall ground rules for the National Ethics Teleconferences:

• We ask that when you speak, you please begin by telling us your name, location and title so that we can continue to get to know each other better.

• During the call, please minimize background noise and PLEASE do not put the call on hold.

• Due to the interactive nature of these calls, and the fact that at times we deal with sensitive issues, we think it is important to make two final points:

• First, it is not the specific role of the National Center for Ethics in Health Care to report policy violations. However, please remember that there are many participants on the line. You are speaking in an open forum and ultimately you are responsible for your own words, and

• Lastly, please remember that these Ethics Teleconference calls are not an appropriate place to discuss specific cases or confidential information. If, during the discussions we hear people providing such information we may interrupt and ask them to make their comments more general.

PRESENTATION

Dr. Berkowitz:

We chose the topic of codes of ethics for today’s call because 1) knowledge of codes of ethics is a required competency for ethics consultants and, 2) because the staff members have identified the need for knowledge building in this area. We expect that by the end of this session participants will:

• Identify professional codes of ethics

• Identify where codes of ethics for various professions can be found

• Describe how professional codes of ethics might relate to an ethics concern, e.g., boundaries issues, matters of conscience

As always we encourage participants to integrate the ethical guidance discussed during the call into field processes.

Let me introduce the faculty for today’s call. From the Ethics Center we have Barbara Chanko. Ms. Chanko is a nurse and a member of the Center’s Consultation Service as well as the VISN 3 IE Point of Contact. I am also pleased to introduce Dr. Cynthia Geppert. Dr. Geppert is an experienced and accomplished ethicist and a psychiatrist at the Albuquerque VAMC. She is currently on detail to the Ethics Center and we appreciate the work she has done in preparing for this call.

Codes of ethics are mentioned in the media, familiar to many educated laypeople, often referred to in the disciplinary actions of professional organizations, and cited in court cases. Yet they seem to have received comparatively less attention in the bioethics literature and especially in the education of ethics consultants. A good review of the history and importance of ethical codes is The American Medical Ethics Revolution: How the AMA’s Code of Ethics has Transformed Physician’s Relationships to Patients, Professionals, and Society.

During this teleconference we will discuss the origins of ethics codes and their strengths and limitations when used in ethics consultation. We will review some of the major ethics codes relevant to VA ethics consultants and how to find them. In the call, we will also consider a few examples of how ethics codes might address a particular ethics concern and apply to ethics consults. In fact, to whet your appetites, I’ll ask Dr. Geppert to start with a few sample ethics consultation requests where ethics codes might be relevant…

Dr. Geppert:

Sure, Ken. A patient with prostate cancer asks his primary care provider to prescribe testosterone replacement therapy because he thinks it will improve his quality of life. The provider is concerned because he knows testosterone can result in progression of the prostate cancer. The provider asks the ethics consultant whether he is obligated to honor the request.

A psychologist working at a VA in a small community is treating a Veteran for PTSD. The psychologist enrolls her daughter in a local soccer program only to find out her patient is the team’s coach. The psychologist asks the ethics consultant if her professional relationship with the coach should affect whether her daughter can still play soccer.

An oncologist prescribes an expensive chemotherapeutic agent for a patient. The inpatient pharmacist reviews the medical record and finds that even with the chemotherapy the patient will only live a few weeks. He is concerned that this may not be the best use of pharmacy resources in light of the likely outcome for the patient and asks the ethics consultant how to proceed.

Dr. Berkowitz:

We’ll be back to more scenarios later, but now let’s get some historical background…

Dr. Geppert:

The oldest and most famous Western “code” of ethics is that of Hippocrates. Codes of ethics are collaborative statements summarizing the ethical ideals required of a professional.

The development of formal codes of ethics is a central aspect of the professionalization of medicine and a brief reminder of the core elements of a profession will help us understand the role of codes of ethics in ethics consultation. Experts generally agree that the learned professions such as law, teaching and the ministry, involve the possession of a specialized body of knowledge and skill that is obtained through a period of education and training. The privileges associated with the learned professions such as public respect and trust are ethically justified by a commitment to serve the good of individuals and society. Entrance to a profession is restricted to those individuals who have acquired the requisite training. Members of a profession work to ensure that colleagues maintain their competence through continuing education. In addition, the qualities of autonomy and self-regulation characterize a profession and carry with them a corresponding obligation to guarantee that individuals accepted into the profession meet high standards of moral conduct. Codes of ethics are used to both communicate and enforce these standards.

The first truly modern code of health care ethics might be the 1847 American Medical Association Code. Historically codes of ethics emerge as a feature of modern complex and multidisciplinary medical care to assist administrators and clinicians to manage the complicated relationships between various health-care professionals. Veatch provides us with a working definition of codes of ethics: “A Code is an ordered collection of injunctions and prohibitions, usually created by an authoritative body and adopted as a statement of ideals and rules for a group or organization.” Ethical codes safeguard the integrity of a profession necessary to maintain the trust of the public.

Dr. Berkowitz:

Good discussion. Cindy, can we now look at the content of ethics codes…?

Dr. Geppert:

Sure Ken. Given the function of ethics codes in protecting the integrity of the profession, codes tend to have prescriptions regarding professional credentials, requirements for competency, and continuing education. There are also so-called rules of “professional etiquette” such as prohibitions against criticizing colleagues to patients, and employing deceptive advertizing. There are provisions delineating appropriate procedures for consultation and referral, how to adjudicate disputes, and guidelines on fees and billing. Codes usually contain detailed and extensive instructions on how to handle allegations of clinical incompetence or unethical conduct. A 2004 study compared physician codes of ethics from professional associations, with the ethics policies of medical groups and health plans to identify gaps, conflicts, and consensus in the statements. The results showed that the majority of all three types of documents mentioned fiduciary obligations although they were more common in physician codes of ethics. Physician codes generally referred to obligations of advocacy, beneficence, and non-maleficence while plans and groups rarely did. There was however little consideration in any of the statements of resource allocation or cost-effectiveness. Highly technical and rapidly changing areas of bioethics such as confidentiality and disclosure may undergo their own evolution in response to technical, legal, cultural and philosophical developments.

Dr. Berkowitz:

Thank you, Cindy, for the background, can you tell us a little more about how ethics codes are used? In particular, three specific areas where codes of ethics may be especially useful to consultants in the field are regarding duties to report impaired colleagues, questions of conscience, and boundaries.

Dr. Geppert:

Ethics codes simultaneously express minimal standards of character and conduct as well as aspirational ideals. They have been called “quasi-moral guidelines”, which means that codes act as guides for professional behavior and also serve as a point of reference for evaluating ethical conduct. Much of the best recent work on the functions of codes of ethics comes from the fields of engineering and Harris has identified six important operations of ethics codes. They are to:

1. Serve as a collective recognition of professional responsibilities

2. Help create a culture in which ethical behavior is normative

3. Serve as a guide in specific situations

4. Use the process of developing and revising a code to foster the formation and growth of a profession

5. Serve as an educational tool, and

6. Communicate to the public that the profession takes itself seriously

Dr. Berkowitz:

Barbara, can you tell staff where they might be able to find the most commonly used codes of ethics?

Ms. Chanko:

Certainly Ken. Let me mention three resources:

The Illinois Institute of Technology Center for the Study of Ethics in the Professions, contains the largest web-based collection of codes of ethics along with helpful background material and other resources.

A smaller but also useful online collection of codes of professional ethics is that of the Center for Applied Ethics at the University of British Columbia .

VA ethics consultants are fortunate to have access through the Integrated Ethics Website under Ethics Resources to the Encyclopedia of Bioethics that includes in its appendix the text of hundreds of codes, oaths and directives. . A password is required and can be obtained by sending e-mail to vhaethics@ or can be found on the Center’s intranet site at .

A list of these sites, and all of the materials we specifically reference, will be provided on the NET call Summary that will be posted after the call.

Dr. Berkowitz:

Thank you. I know there have been some criticisms of ethics codes in the ethics literature. Cindy can you outline some of these problems as they relate to ethics consultation?

Dr. Geppert:

You are right, Ken. Ethics codes have theoretical weaknesses and practical limitations when used in ethics consultation. Let’s look at some of the more valid criticisms of codes of ethics, and how consultants can respond constructively to them. Most codes of ethics express a minimum standard of behavior phrased almost as rules about what a professional must and must not do to remain within the boundaries of acceptable professional conduct. When the minimal standards of ethics codes are used primarily or solely in a disciplinary fashion than they come uncomfortably close to legalism. Codes are most productively used as statements of broad moral considerations that inform decision-making, rather than as providing hard and fast rules for specific situations.

Codes also make general statements regarding ideals of the profession that may seem to abstract or unreachable to be practically useful. Codes are general because they represent a consensus of the profession and reflect the values and views of the majority of practitioners. Codes cannot resolve every unique dilemma and therefore require professionals to use the codes along with other sources of ethics knowledge such as those listed in the CASES approach: precedent cases, VA policy, and published literature.

The most concerning external criticism of the role of ethics codes is their use in self-regulation or policing. There has always been a measure of resistance among professionals to report a colleague or approve sanctions and this is reinforced by the lack of organizational authority to discipline practitioners or enforce meaningful sanctions. A contemporary objection to professional codes of ethics is their assumption that the professional can truly define the best interests of the patient and that permitting professionals to interpret the codes and assign sanctions is an invitation to abuse of power.

An important practical consideration for ethics consultants is that codes may be internally inconsistent and mutually contradictory when they are applied to specific ethics consultations.

Dr. Berkowitz:

Thanks for those interesting comments. I would like to turn now to Barbara to tell us how consultants can use these codes of ethics in their consultation work and especially where in the CASES approach codes may fit.

Ms. Chanko:

And that is one of the major take home points of our teleconference today – how to make ethics codes practical for ethics consultants to use. Let’s divide this discussion into process and content. From a process standpoint there are three steps where ethics codes may fit into the CASES approach that we all use as consultants. The first is in the Assemble step when you would include the relevant codes of ethics in your information gathering. Notice that codes of ethics, ethics guidelines, and consensus statements are actually listed as one of the potential sources of ethics knowledge in the CASES format and in ECWeb. The second is the Synthesize step where the ethics codes could be one of the sources of ethics knowledge applied to the ethics question. The content of specific codes of ethics can be useful in analyzing the ethical concern. The third step where ethics codes may enter in is Explaining the Synthesis: consultants can provide links or copies of ethics codes used in the consultation to the consult participants as a resource.

The Center for the Study of Ethics in the Professions has a series of 7 questions that we have adapted for ethics consultations. Consultants might ask themselves these questions when considering the place of an ethics code in particular consultation:

1. Does the code of ethics give clear guidance related to this particular consultation?

2. Could someone endorsing the opposing course of action or decision find support in the code?

3. Does the code provide conflicting guidance on this type of case?

4. Does the code of ethics conflict with individual conscience? Is a moral compromise possible?

5. Does the code give appropriate guidance in one case but not in another type?

6. If the code provides specific guidance, what general moral principles ground the advice?

7. Does the construction of the code encompass a reasonable spectrum of likely types of cases?

Dr. Berkowitz:

Let’s consider some examples. Dr. Geppert…

Dr. Geppert:

OK, I’ll compare the National Association of Social Workers and American Psychological Association Codes of Ethics pertaining to the duty to report a colleague’s ethical misconduct.

National Association of Social Workers Code of Ethics Provision 2.11 on Unethical Conduct of Colleagues, states:

Social workers who believe a colleague has acted unethically should seek resolution by discussing their concerns with the colleague when feasible and when such discussion is likely to be productive. When necessary, social workers who believe that a colleague acted unethically should take action through appropriate formal channels (such as contacting state licensing board or regulatory body, an NASW committee on inquiry, or other professional ethics committees.)

The American Psychological Association Ethical Principles of Psychologists and Code of Conduct Provision 1.04-1.05, states:

Psychologists who believe a colleague has committed an ethical violation that has, or could substantially harm, an individual or organization, should attempt to resolve the concern informally. If this is not successful they should refer the colleague to state licensing boards, professional ethics committees or appropriate institutional authorities.

As you can see each code includes – as do the statements of most professional organizations – a duty to report unethical colleagues to the proper authorities after interpersonal attempts at remediation have failed. Note also the differences: social workers should attempt to discuss the problem with the colleague if it is feasible and likely to be productive, which leaves quite a bit of room for personal judgment, while psychologists have a more unqualified obligation to attempt informal resolution. The psychologist’s code contains the provision that the unethical behavior has the potential to harm an individual or an organization which is absent from the social work code. Another difference is that psychologists are told to refer the colleague to authoritative bodies while social workers are required to “take action” by contacting the regulatory agency. This example illustrates that the codes express both general and specific duties. In general, the broader the provision, the more room there is for interpretation.

Dr. Berkowitz:

Barbara, can you walk us through another example of code contents from different professions in the area of the conscience clause, which has been generating a lot of consultation activity lately?

Ms. Chanko:

OK, the American Nurses Association Code of Ethics Provision 5.4 Preservation of Integrity, states:

When nurses are asked to participate in an intervention that is morally objectionable, the nurse may refuse to participate. Grounds excluded are personal preference, prejudice convenience or arbitrariness.

The nurse may not withdraw until alternative sources of care have been secured and patient not abandoned.

The American College of Physicians Ethics Manual section on Initiating and Discontinuing the Patient-Physician Relationship, states:

The physician is not required to violate fundamental personal values, medical standards, ethics or the law. If the physician cannot carry out the patient’s wishes or resolve differences, he should consider transfer of the patient.

Dr. Berkowitz:

Interesting, the nursing code is more specific about what objections are not considered matters of conscience, and specifically implies that the nurse’s conscience comes after patient care– the patient cannot be abandoned. The ACP code includes more than just moral objection based on personal values when it describes general medical standards, ethics and laws as the basis for objecting to participate in care. Abandonment is not mentioned in this passage of the code but later in this section on the physician-patient relationship, the code clearly states that abandonment of a patient is unethical and legally actionable.

Dr. Geppert, in preparation for this call, we provided you with several deidentified examples of consultations the Center has received and asked you to think about how codes of ethics might be applied to those questions…

Dr. Geppert:

Yes, Ken that is right and interestingly a number of those consults involved boundary concerns that the majority of professional codes address. The first consult we will look at today involved a personal relationship between a nurse and a patient that was thought might represent a boundary issue. For our analysis of the question we will turn to provision 2.4 of the American Nurses Association Code of Ethics. The code provides a broad statement of values underlying the nursing profession and virtues expected of the nurse in patient care.

“While the nature of nursing work has an inherently personal component, nurse-patient and nurse-colleague relationships have as their foundation, the purpose of preventing illness, alleviating suffering, and protecting, promoting and restoring the health of patients. Nurse patient and nurse colleague relationships differ from those that are purely personal and unstructured, such as friendships or romantic relationships.”

Like all professional relationships, nurse patient relationships are not reciprocal or equal as are friendships. Nurses possess knowledge and skills patient’s need for their health and well-being. Patients trust that professionals will place the best interest of the patient above the provider’s personal priorities. A personal relationship with a patient may potentially compromise that trust and to protect patients against potential exploitation, most codes of ethics have a provision prohibiting these types of relationships.

It also presents a general statement of moral duties that can be interpreted and applied to the case at hand.

• Nurses are responsible for remaining within the bounds established by the purpose of the relationship.

• In all encounters, nurses are responsible for retaining their professional boundaries, not the patient.

• When those professional boundaries are jeopardized, the nurse should seek assistance from their peers or supervisors or take appropriate steps to remove him/herself from the situation

Dr. Berkowitz:

Let’s look at one more example before we have an open discussion from the field. Barbara…

Ms. Chanko:

Sure. Here is another boundary related question referred to the Center from a facility ethics consultation service. They asked, “Would it be ethical for a physician to serve as the primary care provider for his brother?” This is a particular instance addressing the more general question regarding the appropriateness of clinicians providing care for family members and friends. The AMA Code of Ethics responds to this concern in provision 8.19. The opinions in this provision are based on principles I, II, and IV of the Code and are stated as follows:

“Physicians generally should not treat themselves or members of their immediate families. Professional objectivity may be compromised when an immediate family member or the physician is the patient; the physicians’ personal feelings may unduly influence his or her professional judgment, thereby interfering with the care being delivered.”

As with the prior case, the AMA Code also gives more specific guidance that is directly applicable to this question.

• A physician may in an emergency or isolated situation treat himself or an immediate family member when there is no other qualified physician, until another physician becomes available.

• Physicians may provide routine or short-term care for minor problems of family members.

• Physicians except in emergencies should not write controlled substances for themselves or family members.

Referring back to our case, the AMA code would suggest that serving as a PCP for one’s brother is not covered under the emergency or short-term minor care exceptions because the primary care physician provides general medical care for a patient in a long term relationship. The code would provide an ethical justification for the consultant to recommend that the physician not act as his brother’s PCP.

Dr. Berkowitz:

I think when you consider those two examples you see how codes of ethics can help us in our analysis of ethics consultations. When you think about someone saying that a doctor is considering being a physician to their brother; or think about what kind of relationship a nurse can have with his/her patient, it invokes feelings. And it might invoke different feelings among different people. It’s really not enough to base your analysis or recommendation – from an expert consultative point of view – on feelings. You need more learned consensus to inform your thinking or that of the team in order to give your analysis more credence. It’s reassuring to look at the code and say that a thoughtful group has thought about the code and endorsed it as a standard of the profession. In this case that the physician, in general, should not care for his brother, understand why, and under what circumstances there might be an exception. It a similar thing in the case for the nursing code; it sets established consensus thinking on boundaries for those relationships. Informing your analysis with other people’s thinking is very important in ethics consultation. That’s why we’ve included the gathering of relevant ethics knowledge in the CASES approach as well as why we think in a case or non-case, you should always think about what ethics knowledge is out there to inform thinking, reinforce thinking and help provide objective justification for the recommendations being made in that consultation.

What we have done in providing some history, background and content for codes of ethics, is to better prepare you to take these codes of ethics and make them part of your consultation practices. If you do, I think you’ll find they are very useful.

Dr. Geppert, any summary thoughts before our open discussion?

Dr. Geppert:

Thanks Ken. Codes of ethics present shared professional values and understanding as well as a common ethical context. Codes can help clinicians and consultants to think through difficult moral concerns and offer reasoned defenses for their decisions. Codes have been criticized for being too idealistic to be realistic and so broad and conservative in scope that they are not practical. Ethics Codes may also have limited flexibility to respond to new or particularly complicated ethics questions. However, they are meaningful and influential statements of appropriate professional conduct that represent a commitment to act ethically in difficult situations. Codes of ethics, it can be argued, provide a protective framework for both patients and practitioners through the proscription and prescription of virtues and behaviors. Codes of ethics may be especially salient in complex healthcare institutions characterized by complicated interactions between multiple health care professionals and non-professionals.

MODERATED DISCUSSION

Tim Latimer, Madison WI:

From time to time, members of our EC team have been asked to participate on Administrative Boards of Investigation and typically we are viewed as experts in the field of ethical behavior. Often this comes to this issue of whether or not an employee has violated a professional standard specific to their profession. I’ve wondered whether or not we should have a role in this way.

Dr. Berkowitz:

I think it’s critical to clearly understand what “hat” you’re wearing. We know that ethics consultants are often smart, well respected people and clear thinkers who are asked to participate in activities that are important for the facility and maybe should participate on such boards. That does not mean that what they are doing is ethics consultation. Ethics consultation does not include investigations of complaints, violations or consideration of allegations or any investigations of that matter. We’re not the ethics police. So you should not consider that activity an ethics consultation.

Tim Latimer:

Is there any professional organization that represents non-clinically trained or non-classically trained ethicists?

Dr. Berkowitz:

There are several professional organizations. The most visible organization is the American Society for Bioethics and Humanities. I have been a member for many years as are some of our other consultants, and I urge everyone to consider it and to be involved in professional activities as ethicists in some form. I think that the field falls short of some of the things that you talk about and that is because ethics in health care is still a young and emerging field. Bioethics is still struggling for its identity which, if it is like other professions, might take 100 years to truly evolve. The closest thing that ASBH has to a code of ethics is the Core Competencies for Ethics Consultation which published in 1998. It is was a very influential document in setting standards for competencies, knowledge, skills and process areas for ethics consultants; it put formalization for ethics consultation on the map. A number of us have been involved in revising that document and it is expected to be forthcoming in the next few months. There is a move in the society within the ASBH to develop a professional code of ethics for ethics consultants. Two people who have been very involved with that activity are Ken Kipnis from the University of Hawaii and Bob Baker from Union College, Albany, NY. They have been working for at least several years to develop a professional code that is accepted and propagated by our profession.

Alyssa Brown, Greater Los Angeles:

Thank you for the presentation. I just let people know that here are some newer publications for nurses at least in terms of practical applications of the code. See .

Dr. Berkowitz:

Thank you so much. We focused this call on the place of codes as it relates to ethics consultation but for other IntegratedEthics thinkers in the area of Preventive Ethics, codes are an important source to think about in terms of policy development and they might be helpful in performing Preventive Ethics ISSUE cycles. I would imagine as you study an ISSUE that codes might be able to help you think clear about the gap you’re working to close.

Randall Kilgore, Columbia MO:

I am relatively new to this subject matter and this conference call. Will there be a summary or follow-up document from today’s presentation.

Dr. Berkowitz:

Yes, we post a detailed summary from our website and we send an announcement to our mail group when that summary is up and we include all the references that were used on today’s call.

I want urge ethics consultation services to learn more about codes of ethics and to regularly assemble them during ethics consultations and consider them in the ethical analysis.

This concludes our formal review and discussion of the place of codes of ethics in ethics consultation. We know that we have covered a considerable amount of material and we would love to hear what’s on your mind in response to what we’ve said… Please introduce yourself as you share your thoughts, comments or questions...

FROM THE FIELD

We can use the remaining time for further discussion or to address any other ethics topic that is on your mind...

Does anyone else out there use codes of ethics in their ethics work?

Dr. Holmes, Tulsa OK:

I appreciate this. I am a consultant to the ethics committee to the VA in Muskogee. What I sense is people seeing the booklet and the IE program as being the last step in dealing with ethical issues. Do you feel that the IntegratedEthics text and suggestions really reflect what we’ve been hearing today?

Dr. Berkowitz:

Yes, I think that they do. The IE program provides the structure and processes, supported by training and tools, to implement a good ethics program in a health care setting that deals with decisions and actions, systems and process and the culture. I do feel the IE concept has set the stage for promoting ethical health care practices in a health care organization.

CONCLUSION

I want to take the last minute of the call to thank everyone who has really worked very hard on the development, planning, and implementation of this call. It’s not a trivial task, and I really appreciate everyone’s effort, including Barbara Chanko, Cindy Geppert and James McAllister. I also want to acknowledge the EES staff and the VANTS staff who also support these calls.

Please note that our web sites, or contain all of the summaries of prior National Ethics Teleconferences. If you’re on our email list, you will receive details about the posting of the summary of this call; the references that we described; and announcements for upcoming National Ethics Teleconferences. Please let us know if you, or someone you know, does not receive our e-mails and wants to be put on our list, or if you have suggestions about topics for future calls or any question about this or other ethics-related matters. If you send messages to us on Outlook, the address is vhaethics@.

Our next NET Call is tentatively scheduled for Wednesday, June 30, 2010 at 1 PM ET. Stay tuned to our website and your Outlook email for further details about the NET schedule and topics. Thank you very much, everyone, and have a great day!

REFERENCES

Baker, RB, Caplan, AL, Emaneu, LL, Latham SR. 1999. The American Medical Ethics Revolution: How the AMA Code of Ethics Has Transformed Physician’s Relationships to Patients, Professionals and Society. Baltimore: Johns Hopkins University Press.

Berkman, ND. 2004. “Gaps, conflicts and consensus in the ethics statements of professional associations, medical groups, and health plans.” J Med Ethics. 30; 395-401.

Center for Applied Ethics at the University of British Columbia .

Encyclopedia of Bioethics . A password is required and can be obtained by sending e-mail to vhaethics@ or can be found on the Center’s intranet site at .

Illinois Institute of Technology Center for the Study of Ethics in the Professions,

Limentanti, AE. 1999 “The role of ethical principles in health care and the implications for ethical codes.” Journal of Medical Ethics. 25; 394-398.

Nursing World. .

Spicer, CM. 2004. “Nature and Role of Codes and Other Ethics Directives”. In Encyclopedia of Bioethics, 3rd ed., ed. Stephen G. Post. New York: Thompson.

Veatch, RM. 2004. “Medical Codes and Oaths.” In Encyclopedia of Bioethics. 3rd ed., ed. Stephen G. Post. New York: Thompson.

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